Recently completed investigations - ATSB

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Recently completedinvestigations

For more occurrence reports and safety information

visit us at www.atsb.gov.au

Published September–October 2001Occ. no. Occ. date Released Location Aircraft Issue

200104684 28-Sep-01 24-Oct-01 Latrobe Valley Vic. Cessna 172F Ground impact after go-round

200103962 20-Aug-01 23-Oct-01 Perth WA Fairchild Ind. SA227-DC Smoke and fumes in cabin after landing

200003093 1-Jul-00 16-Oct-01 12 km SSW Alice Springs NT Piper PA-28R-201 Pilot misinterpretation of controller's instructions

200003412 1-Aug-00 16-Oct-01 Tennant Creek NT Cessna 404 Response to aileron control input reduced

199905646 25-Nov-99 15-Oct-01 41 km NE Hayman Island Qld Robinson Helicopter R44 Forced landing after burning smell and shudder

200006013 11-Dec-00 12-Oct-01 East Sale Vic. Sikorsky S-76C Infringement of separation minima

200100346 28-Jan-01 12-Oct-01 1.3 km NW Canberra ACT Beech A23A Ground impact following stall after takeoff

199901073 12-Mar-99 8-Oct-01 Melbourne Vic. Boeing 737-377 Right roll and thump during landing gear extension

200100905 15-Feb-01 2-Oct-01 56 km SW Sydney NSW Boeing 737-33A Failure of spoiler cables

200004191 12-Sep-00 2-Oct-01 9 km NW Inverell NSW Cessna A152 Loss of control during solo aerobatic flight

200101952 3-May-01 27-Sep-01 Cooma NSW Beech 1900D Extensive damage by six ducks during takeoff

200000893 13-Mar-00 27-Sep-01 15 km WNW Bankstown NSW Beech D55 Forced landing following double engine failure

200002700 27-Jun-00 27-Sep-01 Broome WA Cessna A185F Ground loop during gusty cross wind

200000868 10-Mar-00 27-Sep-01 11 km SW Warragul Vic. Gippsland GA-200C Collision with terrain during spraying operations

200003793 30-Aug-00 27-Sep-01 Cairns Qld. Cessna A150L Go-round due to aircraft on runway

200103089 13-Jul-01 27-Sep-01 Warnervale ALA NSW Cessna 182G Separation infringement during parachute ops

200000932 18-Mar-00 27-Sep-01 2.5 km NNW Moorabbin Vic. Cessna 210E Ditching following power loss after takeoff

200102697 18-Jun-01 25-Sep-01 Cooktown Qld Fairchild SA227-AC Single engine landing

200003023 5-Jul-00 24-Sep-01 56 km S Maitland NSW Saab AB SF-340B Unsuccessful flight data coordination process

200003091 16-Jul-00 24-Sep-01 13 km NNW Sydney NSW Saab AB SF-340B TCAS Resolution Advisory during approach

200101405 26-Mar-01 21-Sep-01 59 km WNW Devonport NDB Tas.Piper PA-31-350 Engine failure in flight

199903995 9-Aug-99 14-Sep-01 Sydney NSW Boeing Co 737-377 Electrical fault during APU performance monitoring

200000520 9-Feb-00 5-Sep-01 AGAGO (IFR) SA Boeing Co 767-338ER Loss of air situation display

199902419 6-May-99 5-Sep-01 9 km ENE Perth VOR WA Boeing Co 737-376 Infringement of radar separation

As reports into aviation safety occurrences are finalised they are madepublicly available through the ATSB website at www.atsb.gov.au

Australian Transport Safety Bureau

FLIGHT SAFETY AUSTRALIA, NOVEMBER–DECEMBER 2001 < 47

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THE information I give you is as aconcerned pilot. The problem isassociated with a lack of parts and a

loyal desire to keep the aircraft flying," thereport reads.

In another report: “I was concerned for the

safety of the pilot on two occasions…however

I am concerned most about the safety culture

of the [parachuting centre].”

Yet another report outlines a personal

experience: “I got my weather and NOTAM

from NAIPS. I did not receive a NOTAM on

[destination]. I joined mid-downwind for

the runway and the windsock confirmed this.

I did not fly over the windsock and so did not

see the white cross when I landed.”

Another report relates an incident when an

electric wheel chair was unloaded from the

hold and wheeled to the stairs for the

passenger. “The battery had not been

correctly packed for air transportation,” the

ground crew said.

In another, a concerned pilot reports the

behaviour of others – airline pilots using

121.5MHz as a chat frequency. ‘Two pilots

from [airline] continued a lengthy conver-

sation on their forthcoming layover. Lately

pilots from [another airline] have also been

chatting on this frequency.”

These reports all have something in

common: they were all submitted confiden-

tially.

More than three hundred reports are

submitted every year through the

Confidential Aviation Incident Reporting

System, known as CAIR, by pilots, air traffic

services personnel, cabin crew, maintenance

workers, aircraft passengers and others.

In many cases, pilots have learnt about

flying from their experiences and want to

share them with fellow pilots. In others,

reporters may only be able to highlight

problems through a CAIR report, knowing

that it would escape the mandatory reporting

route. In some cases, it is whistle blowing.

Australians have generally embraced the

idea of reporting - covering a wide variety of

issues that they see as genuine safety concerns

willingly and voluntarily.

But do CAIR reports make a difference?

CAIR is the only system that captures

information that would otherwise go

unreported and where lessons can be learnt

from others. It is therefore well placed to help

identify and rectify aviation safety

deficiencies. The reporter’s identity always

remains protected.

But it is not the only method of reporting -

many companies have their own internal

safety reporting programs. What CAIR does

offer is an alternative process when the

company program or system is ineffective.

Perhaps the last word comes from the

following report. The pilot was flying a

general aviation aircraft from Camden for a

Sydney Victor One via Stanwell Park and after

some radio talk with Sydney was cleared to

enter the harbour area approaching South

Head. With two radio frequency changes

made, and at 600 feet, the pilot recounts:

“Suddenly I recognised a pair of landing

lights, a flash of white with a blue haze, a set

of floats and a Cessna engine cowling.

A numbness swept over me as I realised

that I had not had time to swear. A float plane

had passed within metres of my aircraft,

tracking south between me and the coast and

I had no warning of it.

Who was at fault? I felt I had kept a

reasonable look out at all stages of the flight.

However, this was obviously not the case.

Throughout the flight I had been preoccupied

with Sydney Terminal and had not kept a

listening watch out on 120.8Mhz. Perhaps I

should have had the other radio on and

maintained a dual listening watch, something

I will do in future.

In hindsight I am neither angry nor

indignant, just relieved that a misadventure

did not occur.”

If you would like to make a confidential

report, call the ATSB’s CAIR manager, Chris

Sullivan on 1800 020 505, or complete a CAIR

form, which is available from the internet site

at www.atsb.gov.au.

He’s only too happy to hear from you. And

so might others in the industry. ■

You might learn aboutflying from this

Chris Sullivan, CAIR Manager

Did youknow?

?You are now reading aspecial supplementprepared by theAustralian TransportSafety Bureau which isindependent of CASAeditorial.

We aim to keep youinformed of the latestpublished reports, andaccident and incidentfindings and we're keento hear from you.

You can contact us by [email protected] or on 1800 621 372.

“


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Safety briefsHarness safety heightenedSafety Brief 200000893

Three significant factors were found during

the investigation into the forced landing of a

Beech Baron on 13 March 2000 in which the

pilot suffered severe head and facial injuries.

The pilot was not adequately prepared for an

assigned instrument approach in instrument

meteorological conditions (IMC); did not

change fuel tank selection when the auxiliary

tanks were exhausted; and the shoulder

harness was not correctly installed.

The pilot had entered controlled airspace

without a clearance 20 NM north west of

Bathurst. Issued a clearance, the pilot tracked

for Bankstown and entered IMC and

requested a Bankstown Radar Two arrival.

The pilot was instead cleared for a Runway

11C Radar/Bankstown NDB/Sydney DME

instrument approach and acknowledged the

instruction. The controller told the pilot the

aircraft was right of track and cleared it to

track to Bankstown on that procedure. The

pilot then contacted Bankstown tower and

was asked which approach the aircraft was

flying. The pilot confirmed flying a GPS

approach.

The pilot later reported not having flown

the assigned approach before. When not

visual at 600ft the pilot commenced a

climbing turn onto a reciprocal track to divert

to Bathurst.

After turning the left engine failed followed

by the right. The aircraft impacted the ground

in a grass-covered gully. ■

Maintenance fatigue issuesSafety Brief 200100905

Maintenance engineers had worked excessive

hours and were fatigued when they mis-

routed Boeing 737 spoiler cables during their

replacement following an incident in which a

cable failed on 15 February 2001.

The cable failure became apparent during

the descent into Sydney when the aircraft

rolled to the right after the speed brake was

selected with the autopilot engaged. The

autopilot was disengaged and the speed brake

reselected with the same result. The flight

continued and the aircraft landed without

incident, was repaired and returned to

service.

The mis-routed cables were found when

the aircraft was inspected during routine

maintenance thirteen days later. The

operator’s investigation found that the

engineers who had replaced the cables had

worked more than 24 hours and flown from

Brisbane to Sydney that same day.

In February 2001, the ATSB released an Air

Safety Information Paper, ATSB Survey of

Licenced Aircraft Maintenance Engineers in

Australia. One of the safety deficiencies

identified was a lack of programs to limit the

extent of fatigue experienced by maintenance

workers. As a result of that deficiency, the

ATSB issued safety recommendation

R20010033 to the Civil Aviation Safety

Authority (CASA) in February 2001 which

stated:

‘The Australian Transport Safety Bureau

recommends that CASA ensures through

hours of duty limits, or other means, that

maintenance organisations manage work

schedules of staff in a manner that reduces the

likelihood of those staff suffering from

excessive levels of fatigue while on duty.’

CASA has addressed the issues of a fatigue

management program through a Notice of

Proposed Rule Making. ■

Centurion power loss mysterySafety Brief 200000932

A number of factors were considered but no

firm conclusion reached in the investigation

into the ditching of a Cessna 210 Centurion

after take off on 18 March 2000.

The aircraft was successfully ditched in a

quarry filled with water when it was unable to

climb beyond 100ft after takoff. The pilot and

both passengers exited the aircraft but one

passenger drowned.

The aircraft had used more runway than

book figures indicated for the conditions

during take off, however the pilot did not

notice the reduced aircraft performance until

the landing gear was retracted shortly after

becoming airborne. There was no sudden loss

of power.

No faults were found with any of the

aircraft’s systems, engine, and propeller or in

its handling by the very experienced pilot.

Even though a defect was found in the fuel

selector valve that restricted the flow of fuel to

the engine, this would not have resulted in the

performance loss that was observed in the

accident.

The loss of performance was consistent

with a restricted fuel supply. ■

48 > FLIGHT SAFETY AUSTRALIA, NOVEMBER–DECEMBER 2001



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Pilot incapacitation likelySafety Brief 200004191

Pilot incapacitation leading to a loss

of control was a likely factor in the accident

involving a Cessna A152 Aerobat on

12 September 2000.

The pilot was on a solo aerobatic training

flight to practise for a competition and had

been having problems conducting stall turn

manoeuvres during a previous dual

instruction flight. There were no witnesses to

the impact.

Examination of the accident site revealed

that the aircraft impacted the ground in

balanced flight at high speed in an attitude of

approximately 70 degrees nose down. The

engine was producing high power at impact.

Examination of the wreckage did not reveal

any technical defect that would have

contributed to the accident.

The pilot had a long history of hiatus

hernia and had taken medication but had not

undergone surgery. At the time of the

accident the pilot was not taking prescribed

medication. For about 10 years the pilot had

been prone to fits of coughing after eating

and drinking. During these attacks, the pilot’s

ability to perform other tasks was impaired.

About 45 minutes before the dual flight, the

pilot had eaten a hamburger and chips.

During the dual flight, the pilot had suffered

a fit of coughing during which time attention

to flying the aircraft was reduced.

Toxicological examination of the pilot

revealed the presence of the drug doxylamine,

at a concentration of 4.7 mg/kg in the liver.

The reason for the pilot’s loss of control of

the aircraft was not conclusively established.

Significant factors identified in the investi-

gation were that the pilot suffered from a

medical condition that could have adversely

affected the ability to fly the aircraft, and the

pilot lost control of the aircraft and did not

regain control before the aircraft impacted

the ground. ■

Ground loopSafety Brief 200002700

A gusting crosswind and aircraft centre ofgravity close to the aft limit were the keyfactors in the ground looping of a Cessna185 on 27 June last year.

The pilot reported that following a normal

landing, and after the tail wheel had been

lowered to the runway, the aircraft nose

commenced to yaw to the right. The pilot

estimated that the aircraft was travelling at

about 20 KTS and despite applying full

rudder and the use of differential braking it

was not possible to regain directional control

and the aircraft ground-looped.

The left main gear-leg collapsed and the

outboard portion of the left wing was

substantially damaged when it struck the

surface of the runway. The propeller was also

damaged on contact with the runway. The

pilot and three passengers were not injured

and vacated the aircraft without assistance.

The pilot had been endorsed on the aircraft

approximately one week before the accident

and had significant experience operating

other tail-wheel equipped aircraft. The pilot

had logged 18 hours on the Cessna 185.

The weather at the time of the accident was

a southerly wind with gusts recorded up to

11 KTS. The report concluded that the pilot

could have encountered a right crosswind of

up to 10 KTS during the landing. Although

this was within the aircraft manufacturer’s

demonstrated crosswind limit of 15 KTS the

investigation calculations showed the aircraft

centre of gravity was close to the aft limit

although still within published limits.

The weather conditions prevailing at the

time of the accident would have made the

aircraft more difficult to control, especially

during the later stages of the landing roll as

the aircraft slowed down and the rudder

became less effective. Directional control at

lower speeds becomes increasingly dependent

on tail-wheel steering and the use of differ-

ential braking. The directional instability

would have been further exacerbated with

any sudden increase in crosswind component

due to the gusty crosswind conditions. ■

Stall during climb fatalitySafety Brief 200100346

A Beech Musketeer stalled during the climb

after takeoff on 28 January 2001 and was not

recovered before it impacted the ground

fatally injuring all four occupants.

After the aircraft took off it climbed at a

shallow angle, which witnesses reported was

below the normal climb profile. When the

aircraft reached a point about 100 m beyond

the upwind threshold of the runway, the

tower controller informed the pilot of

inbound traffic directly ahead of the aircraft.

The controller noticed that the aircraft was

exhibiting ‘wobbles’ and became concerned.

Witnesses reported that the aircraft slowly

climbed to about 300 ft and then seemed to

lose altitude. The aircraft then continued

tracking outbound in a shallow climb on

runway heading before the right wing

dropped. The aircraft then rolled to the right,

assumed a steep nose-down attitude and

began rotating. After one turn the aircraft

impacted the ground in a steep nose-down

inverted attitude. The pilot and passengers

had arrived at the pilot’s home in the early

hours of the morning after driving from

interstate. The pilot was up at 0630 EST on

the day of the accident.

During the investigation no aircraft defects

were found and the aircraft was operating

within its correct weight and balance limits. It

was considered that operating just under

maximum gross weight at a density altitude

of 3,400ft would have reduced the aircraft’s

acceleration and climb performance.

As the aircraft was lower than the normal

climb profile, rising terrain ahead might also

have affected the pilot’s assessment of the

aircraft’s nose attitude with respect to the

horizon or its rate of climb with respect to

terrain. Consequently the pilot may have

selected a higher nose attitude. The pilot may

have been distracted while looking for

inbound traffic during the initial climb. ■


THIS report from the TransportationSafety Board of Canada(A99AO046) highlights the need for

continued care and vigilance in the use ofground-handling equipment to ensure safemovement to and from aircraft forpassengers, aircrew and ground personnel.

In March 1999 a five year-old child wasinjured during disembarkation from a B767at a Canadian airport. The aircraft wasparked on the open ramp away from anaerobridge.

After the first 10 passengers had left theaircraft a flight attendant exited the aircraftcarrying an infant in a car seat. Whenthe flight attendant stepped on to thepassenger stand he noticed it wasdescending slowly away from theaircraft. As he turned to tell the in-charge flight attendant, the infant’s fiveyear-old brother, who was followingwith his mother, stepped out of theaircraft and fell between it and the stairsto the apron below. The child suffered abroken arm and lacerations to the headin the fall and was taken to hospital fortreatment and observation.

The locking mechanism used to holdthe upper stairs in position is a fairlysimple mechanical device. The pawlthat prevents the stairs from descending

is held in place against the dog rail by aspring and released by energising a solenoid.In this occurrence the pawl had onlypartially engaged the dog rail and afterseveral passengers had travelled over thestairs had slipped off. This allowed the upperstairs to descend away from the aircraft.According to the report it was unclearwhether this was due to a weakness in thespring, a mechanical resistance in themechanism or a combination of both. In anycase proper functioning of the lockingmechanism was impeded.

Investigation findings: The lockingmechanism was not functioning properlyand as a consequence disengaged andallowed the upper stairs to descend awayfrom the aircraft. There was no policy inplace requiring the passenger stand operatorto do a close visual inspection of the lockingmechanism to ensure full engagement.

Passenger stand operators reported thatthey would take only a cursory look at thelocking mechanism when leaving thevehicle. Any visual inspection would havebeen impeded because the pawl, the dog rail,and the background were all painted the

same dark green colour and on thisparticular vehicle a support braceimpeded the operator’s view. Operatorsof the passenger stand reported that theyhad not received formal training on theoperation of the equipment.

Other contributing factors to theoccurrence were the failure to follow themaintenance schedule and the absence ofa requirement to visually inspect thelocking mechanism of the passengerstand before use.

Safety action taken: Since theoccurrence the company has completed a comprehensive inspection of allcompany passenger stands. All pawlmechanisms were painted in contrasting


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by Peterlyn Thomas

Gap widensto approx30–40 cm

Heightof fall,approx2.25 m

Airstairs beginto retract

The ATSB collects and analyses data from accidents and incidents involving aircrew, ground

personnel and passenger safety. In this issue of the ATSB Supplement, a selection of Australian

cabin safety occurrence briefs are summarised and one from the Transportation Safety Board of

Canada.

Safety first –aircrew, ground personnel and passengers

Safety first –


colours to facilitate determination of thepawl position and support braces wererelocated to prevent the impediment of theoperators’ view of the pawl. All airstairs unitswere put on a weekly follow-up routine toensure all checks are completed on time.

The company, the TSB and the Canadianregulator Transport Canada, have dissem-inated details of the occurrence to local andinternational air transport operatorsregulators and industry associations to alertother operators using similar equipment ofthe potential for injury and the steps thatmay be taken to avoid similar occurrences.

Occ No. 200100741, 22 February 2001At top of descent to Los Angeles the cabincrew of a Boeing 747 aircraft reported smokeand fumes emanating from the cabin ceilinglocated in the vicinity of the rear right side(R5) emergency exit door. Smoulderingpaper tissues were found in an overheadlight fitting. Cabin crew removed the tissuesand discharged a fire extinguisher onto thelight fitting, tissues and surrounding area.The cabin crew remained in the vicinity andmonitored the area until passengersdisembarked at Los Angeles.

The company reported that the lightfitting is a night light and is always on. Thelight has a blue plastic cover that shouldalways be in place and which was not fittedon this occasion.

The investigation was unable to determinewhy or who placed the tissues in the lightfitting.Safety action: The company issued an‘Important Information’ bulletin to flightattendants advising that any visible cabinlight fitting must have a protective grill orglass covering the bulb.

Occ no. 200104168, 21 August 2001During the cruise the passenger seated in 56Cwas warned several times for lightingcigarettes. Most cigarettes were extinguishedand confiscated by the crew but one wasdropped and ignited a blanket. The cabincrewmembers were quick to extinguish thesmouldering blanket. The passenger was off-loaded in Bangkok.

Occ No. 200104464, 5 Sept 2001During a flight between Melbourne andSydney a smouldering fire was detected andextinguished in the waste bin of the aft toiletof the aircraft. A particular passenger wasstrongly suspected of smoking in the toiletsduring flight and the pilot in commandrequested that security staff meet the aircraftupon arrival in Sydney. The aircraft landedwithout further incident.

Occ No. 200103578, 10 July 2001The aircraft was on climb passing FL200when a passenger sustained a head injuryfrom a bottle of liquor that was accidentallydropped from an overhead locker by anotherpassenger who was removing a piece ofluggage. The injury was treated immediatelyby the cabin crew to stop the blood flow. Aparamedical team met the aircraft on arrivalat Rome.

Occ No. 200103478, 15 July 2001During disembarkation a passenger wasstruck on the head by a metal scooter that fellfrom on overhead storage bin. The passengerreceived a bleeding cut to the head, was givenfirst aid and attended by the Rescue FireFighting Service. The passenger was latertransported to a local medical centre fortreatment.

Occ No. 200100393, 24 Jan 2001During the cruise cabin crew were requiredto abruptly cease cabin service when theflight crew turned on the ‘fasten seat belt’ signdue to severe turbulence associated withthunderstorm activity. They were not able tosecure the cabin prior to landing and as aresult the aircraft landed with the cabininsecure. The pilot in command reportedlater that he did not consider it safe to turnthe sign off during the descent.

Occ No. 200103943, 8 August 2001During the cruise a passenger seated in 20Cwas struck on the head by a plastic bottle fullof water, which had been stored in theoverhead locker by a cabin crew member.The passenger later collapsed, became ill andrequired medical attention. An ambulancewas organised to meet the aircraft on arrivalat Darwin.

Occ No. 199902180, 24 April 1999The aircraft was cleared for takeoff when theflight attendant advised the pilot that a cathad escaped from a cage in the cargo holdand was loose in the cabin. The flightattendant locked the cat in the toilet whilethe pilot returned the aircraft to the ramp.The cat was removed through the toilet doorwithout further incident.

Occ No. 200102090, 3 May 2001During the cruise the crew noticed smoke ina rear toilet. The cabin crew found asmouldering tissue box that appeared to havebeen used to extinguish a cigarette and thenwater used to extinguish the potential fire.At the time the ‘no smoking’ sign wasextinguished. ■

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Photographs of the burnt out SaudiArabian Airlines Lockheed Tristar atRiyadh on 19 August 1980 followingan emergency landing. All 287passengers and 14 crew on board diedfrom smoke inhalation from a fire inthe aft cargo hold which startedshortly after takeoff. Despite thesuccessful landing the crew wereunable to open the doors. Emergencyservices took 20 minutes to open onedoor. A serious breakdown of crewcoordination was cited as one of thesignificant factors in the disaster.



Source: www.airdisaster.com



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THE Confidential Aviation IncidentReporting (CAIR) system helps toidentify and rectify aviation safety

deficiencies. It also performs a safetyeducation function so that people can learnfrom the experiences of others. The reporter’sidentity always remains confidential. To make areport, or discuss an issue you think isrelevant, please call me on 1800 020 505 orcomplete a CAIR form, which is available fromthe Internet at www.atsb.gov.au

In the Jul-Aug 2001 issue, three reportswere published that highlighted concerns withthe use of mobile telephones in the vicinity ofaircraft. At the time of publication, responseshad not been received from the airlinesconcerned or from CASA. I am pleased toadvise that the issue is being addressed byCASA and two of their responses arereproduced below.

Chris SullivanManager CAIR

CAIR reportsMobile telephonesFirst response from CASA (CAIR 200100004)

Regarding the use of PEDs (personalelectronic devices), current regulations relateonly to safety in flight. CASR 91.105 requiresthe operator and the pilot-in-command toprohibit or limit the operation of a PED onboard an aircraft if there is reason to believethe PED may adversely affect the safety of theaircraft. CASR 91.15 provides the pilot-in-command with the necessary authority tocontrol the use of potentially hazardousPEDs on board his/her aircraft and obligespersons on board to comply with legitimatesafety instructions.

Legislation to control the use of mobilephones during refuelling is currently beingdeveloped. The draft NPRM for Part 91states:

Rule 3.7 The aircraft operator and the person

in charge of the aircraft fuelling operation

must take all reasonable steps to ensure that

all devices capable of emitting radio-

frequency energy are turned off when within

six metres of the aircraft’s fuel filling points

or fuel vents, or the fuelling equipment,

unless the devices have been designed or

certificated to an industry standard for use in

fuelling zones.

The examples provided in the FYI will beprohibited once the new legislation relatingthe use of PEDs during refuelling isintroduced (planned for November 2002).Second response from CASA (CAIR 200102506)

I thank you for your letter of 8 June 2001requesting information to address concernsraised in a CAIR report relating to mobilephone use.

The regulation to control the use of mobilephones is contained within the proposedCASR Part 91 NPRM (Notice of ProposedRule Making), which is to be released forpublic comment within the next threemonths.

The proposed regulation that controls theuse of mobile phones by a passenger duringflight provides for a penalty of up to 25 units(currently $110 per unit) for knowinglybreaching this regulation. The operator andthe pilot-in-command are required toenforce this requirement. Failure to do somay incur a penalty of 25 units. Operatorswho hold an Air Operators Certificate will berequired to establish procedures acceptable toCASA to ensure these regulations areenforced.

I trust this provides you with the necessaryinformation to address the concerns raised bythe author of the CAIR report.

Flight in poor weather conditions(CAIR 200100463)

A very heavy thunderstorm with an associatedsquall line had passed over [regional location]and was moving to the south. Although it wasstill daylight at 1900 EST, the sky was verydark associated with the weather. As I watchedthe storm moving south towards the Ranges, Iwas amazed to see [aircraft type] appear from

out of the storm on a wide (7-8 NM) rightbase to runway 07.

Was air traffic control putting this aircraft atrisk or was it the crew putting their passengersat risk? The dangers of windshear andmicrobursts associated with thunderstorms arewell documented. Has the airline been placingtoo much emphasis on the commercialimperatives to the detriment of passengersafety?

Response from Airservices Australia: I am

writing in response to the above report, which

relates to an alleged flight at [regional

location] during adverse weather.

Airservices is unable to comment on the

circumstances of this report. Suffice to say that

the ultimate decision on the suitability of

flight during adverse weather rests with the

pilot. The air traffic system provides the pilot

with flight information to assist the pilot to

make this decision.Response from operator: I am in receipt ofyour letter regarding a safety concernexpressed about one of our aircraftconducting an arrival into [regional location]on [date]. The answer to the question ‘wasthe crew putting their passengers at risk?’ isno.

[Airline] provides ample educationaldocumentation to our flight crew on theproblems of windshear and microburstsassociated with thunderstorms. Our crewsregularly conduct windshear and microbursttraining and are checked by our trainingdepartment on the correct identification andresponse to encounters with windshear andthunderstorm avoidance.

The implication the airline has beenplacing too much emphasis on thecommercial imperatives to the detriment ofpassenger safety is nonsense, and to bedismissed as simply ill-informed speculation.

MED 1 priority vs Noiseabatement (CAIR 200100543)

Re: AIP Australia Noise Abatement Procedures,Brisbane, Queensland - Page 1 - Note 2.

I always believed MED 1 indicated a life-

Confidential AviationReportingIncidentIncident



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threatening situation - are there now to belevels of this? Surely, duty of care dictates thatMED 1 aircraft are afforded every assistance.

I would have hoped to see MED 1 operationsgiven a blanket exemption from noiseabatement, not treated as this note in the AIPtreats them.CAIR note: The Note 2 that was referred toin the above CAIR report was in AIP DAPEast Amendment 79 effective 22 February2001. It was detailed as follows:

Note 2: Pilots of MED 1 priority aircraft

shall advise ATC if they have a level of

urgency that requires exemption from

compliance from Noise Abatement

Procedures. This notification should be made

as early as practicable. If exemption is

requested ATC will facilitate this request.Response from Airservices Australia: I amwriting in response to the above report,which relates to concerns with MED 1category operations.

Airservices agrees in principle with thereporter’s notion that medical priorityaircraft should be afforded all considerationpossible to achieve the nature of their task.

We cannot however provide carte blancheexemption from legal obligation based purelyon the category of operation. Our obligationto ensure compliance with a raft of legalrequirements can only be varied as a result ofa specific request from the pilot.

The management of Brisbane Centre AirTraffic Management has instigated a changeto MATS to reflect maximum cooperation toMED 1 category aircraft. We will continue todo everything in our power to assist theseoperations.

Problems at uncontrolledaerodrome (three reports) CAIRs 200101733, 200101938 & 200101942)

Report 1 (CAIR 200101733)

The main operator at [regional aerodrome] is[name of organisation]. The instructors andsome of the students are a law unto themselvesand often use the MBZ frequency for otherthan standard calls and have abused otherMBZ users over the radio. For a trainingenvironment, this is extremely bad practice andencourages poor attitudes and airmanship.CASA should monitor this frequencyoccasionally and counsel offenders.Report 2 (CAIR 200101938)

During the last 18 months I have observed[operator] flight training operation and notednumerous breaches of regulations and poorairmanship. I am submitting this CAIR as Ibelieve [their] operational standards have

deteriorated further in recent months to a pointwhere I consider them to be a hazard to otheroperators at [location] and a danger tothemselves. I have a record of aircraftregistrations, dates and other witnesses namesfor many of these occurrences.

These observations include the following:

1. Simulated engine failure in a PA-44

Seminole after take-off (200ft AGL) at

night.

2. Practice circling approaches in VMC

in a C90 Kingair and turning final

200–300ft AGL over the airfield fence.

3. Continuing practice instrument approaches

through the circuit area rather than discon-

tinuing the final approach no closer than

2 NM from the airfield as per ‘Special

Procedures’ in the ERSA.

4. Using a cross runway to practice rejected

take-offs in a PA-44 in a direction towards

the active runway where touch and go

circuits were being conducted. They

appeared to use maximum braking to pull

up just short of the active runway. (I carried

out a go-round as I had doubts about the

ability of the PA-44 to stop short).

5. Conducting crosswind circuits and

subsequently having simultaneous runway

operations with five aircraft in the circuit.

(Max. allowed is three aircraft)

6. Not following the requirements for

conducting straight-in approaches.

7. Giving false position reports in the circuit.

For example, I recently gave a base call and

an instructor in a PA-44 then called on a

two-mile final. When I finally sighted the

aircraft it was obvious that it would have

been six miles out and tracking for a

straight-in approach at the time of the two-

mile call.)

8. Commanding other non-company aircraft

to go-round to facilitate their own arrival.

9. Flying excessively large circuit patterns,

inconveniencing other users. When

conducting circuits on RWY 35 aircraft are

up to five miles off the coast, outside gliding

range to land and life jackets are not worn.

10.Total lack of R/T discipline. This includes

abusing and lecturing other operators,

accusing other operators of breaching

regulations over the radio and using the

MBZ frequency as a company chat

frequency. This abuse over the radio creates

a hostile operating environment and is

particularly intimidating to solo students

and inexperienced pilots.Report 3 (CAIR 200101942)

At approximately 12:40 on [date], I was

number two at the holding point for runway

17, at [location]. There were a number of

aircraft in the circuit. [Aircraft A] called

turning base for a stop and go. It landed, came

to a complete stop, a person who I believe was

an instructor stepped out of the aircraft onto

the runway and strolled across the airfield.

This caused two aircraft to go around one

being [aircraft B]. [Aircraft B] asked the pilot

[of aircraft A] his intentions, as he was causing

traffic to go-round. Words were exchanged

between [B] and another pilot (unknown

identity – I believe he may have been a fellow

instructor).

Due to the nature of the airspace at

[location] there is often non-compliance of the

regulations particularly in the circuit area and

bullying over the radio particularly between

[different] operators.

Response from CASA: It has been difficult

to substantiate many of the claims made in

the CAIRs. We have spoken to the operators

and conducted surveillance at the airfield

without seeing anything untoward.

There have been three meetings between

the various operators at the airfield and the

airport management in order to improve

procedures and create a better working

relationship between the parties. They have

resolved many issues and have produced

amendments to the local operating

procedures to improve the safety,

[Location] is a very busy training airfield.

A few years ago an MBZ was imposed

because of increased training traffic and

consideration has been given to requiring a

tower facility during busy periods. The

operators have been reminded of this fact

and encouraged to take steps to improve the

operations at the airfield if they wish the

MBZ procedures to be retained.

We intend to continue close monitoring of

operations at [location]. ■

ATSB is part of the Commonwealth Department

of Transport & Regional Services

Documents

Recently completed investigations - ATSB